Initiation and Use of Tolterodine for Urgency Urinary Incontinence

1. Non‑pharmacologic First‑Line Measures

Bladder (pelvic floor) training is the recommended first‑line therapy for urgency urinary incontinence, supported by a strong recommendation with moderate‑quality evidence; a minimum duration before considering drugs is not mandated, but failure of conservative measures must be documented. 1
In patients with obesity, concurrent weight‑loss programs and regular exercise should be instituted because they effectively reduce incontinence symptoms. 1

Tolterodine is indicated only for urgency urinary incontinence and not for stress (effort) incontinence. 1
The recommended initial regimen after failed bladder training is tolterodine 2 mg taken twice daily; this dose is preferred by the majority of patients. 1

High‑quality evidence shows that tolterodine 2 mg bid produces a significant objective clinical improvement at 12 weeks of therapy. 1

Discontinuation rates due to adverse events with tolterodine are comparable to placebo, reflecting a favorable tolerability profile (high‑quality evidence). 1
The Number Needed to Harm (NNTH) for any adverse event with tolterodine is 12, which is better than oxybutynin (NNTH = 16) and worse than fesoterodine (NNTH = 7).
Drug NNTH (adverse events)
Tolterodine 12
Oxybutynin 16
Fesoterodine 7
Tolterodine is associated with significantly less dry mouth compared with oxybutynin (high‑quality evidence). 1
Common anticholinergic side effects (dry mouth, constipation, blurred vision) occur with all antimuscarinics but are significantly less frequent with tolterodine than with oxybutynin. 1

Oxybutynin should not be used as first‑line therapy because it has a higher discontinuation rate (NNTH = 16) and a greater risk of cognitive decline in older adults. 1

Bladder training is the recommended first-line treatment for urgency urinary incontinence, with a strong recommendation and moderate-quality evidence 2, 3
Antimuscarinic medications, such as tolterodine or darifenacin, are recommended as first-line pharmacologic therapy only if bladder training is unsuccessful, with high-quality evidence 4, 5, 2

Tolterodine and darifenacin have a favorable tolerability profile and should be considered first-line pharmacologic therapy, with high-quality evidence 4, 5, 2, 6
All pharmacologic therapies are equally efficacious at managing urgency UI with moderate benefit in achieving continence rates, with moderate-quality evidence 6, 7

Tolerability differs significantly between agents, with tolterodine having fewer adverse effects than oxybutynin, and discontinuation due to adverse effects being higher with fesoterodine than tolterodine, with high-quality and moderate-quality evidence 5
No significant difference in discontinuation rates between solifenacin and tolterodine, with moderate-quality evidence 5

Patient adherence to pharmacologic treatments for UI is generally poor due to adverse effects, with moderate-quality evidence 8
When selecting a medication, consider tolerability, adverse effect profile, ease of use, and cost, with moderate-quality evidence 7, 8
For obese women with urinary incontinence, weight loss and exercise are strongly recommended, with a strong recommendation and moderate-quality evidence 6
Pharmacologic therapy is not recommended for stress urinary incontinence, with a strong recommendation and low-quality evidence 8